HESI MAKEUP DAY

in which order would the nurse apply the nursing process while providing care for clients?

1. assessment 2. diagnosis 3. planning 4. implementation 5. evaluation

while conducting an assessment the nurse finds the client shivers uncontrollably and experiences memory loss, depression, and poor judgment. which temp would the nurse associate with these finding

33C

during an assessment which finding prompts the nurse to don a protective gown

excessive wound drainage

which pulse site would the nurse use to perform the allen test?

ulnar

when conducting an assessment of a client who does not speak english and an interpreter is unavailable, which action would the nurse not utilize?

using medical terminology

while performing a physical assessment of a female client, the nurse positions the client in a left lateral recumbent position. which body sys would the nurse assess in this position

vagina rectum

which nurses statement indicates the clients interview is coming to a close?

"I have just one more question for you"

while assessing a clients vascular system, the nurse finds a diminished and barely capable pulse strength. which documentation would the nurse utilize in this situation

1+

the nurse assesses an older client reporting chills and determines the client has a fever. which rectal temp would the nurse anticipate

101.3

while providing care for a client with a heat stroke, the nurse measured and noted the temp as 39C. which temp would the nurse document in F

102.2

for a client admitted to the hospital after an accident, the nurse uses the glasgow coma scale. client is alert and opens eyes when there is a sound or when someone talks. when asked questions, client answers in confused manner. client obeys commands such as being asked to move leg. which score would they get

13

a client weighs 150 lbs and is 5 ft 7in tall. which numerical value reflects this clients BMI

23.53

which respiratory rate would the nurse expect for a 2 yo child

30 breaths

which clients body temp indicates moderate hypothermia

88 92

the nurse assesses a clients pulse and documents the strength of the pulse as 3+

FULL

during a physical examination, which assessment would the nurse anticipate when a client is placed in the lithotomy position?

Female genitalia

A client in the second trimester of pregnancy arrives at the clinical for a general health checkup, including a pelvic exam. For which position would the nurse prepare the client?

Lithotomy position

after performing an optical assessment on a client, a primary HCP notices impaired near vision. Which other finding would confirm the clients diagnosis as presbyopia?

Loss of elasticity of the lens

when preparing to assess a client with active TB, which piece of PPE would the nurse put on before entering the clients room

N95

the nurse documents data that was gathered during an assessment in a clients medical record. Which action would the nurse take to ensure that the data is meaningful to other health care providers?

Record objective information using accurate terminology

during orientation, an RN reviews content about 3rd heart sound S3. which participants statement indicates ineffective learning

S3 is normal in pregnant women

which nursing intervention would the nurse use to encourage the client to verbalize their personal health problem?

The nurse leans forward attentively during the discussion

while assessing a client, the nurse finds inflammation of the skin at the bases of the clients nails. which event or disorder would the nurse associate with the reason behind this condition

Trauma

which assessment finding of the skin refers to elasticity?

Turgor

while collecting a clients urine sample, which condition would the nurse suspect if the sample has a strong odor of ammonia

UTI

while examining a client, the nurse finds a 0.6 cm circumscribed elevation of the skin filled with serous fluid on the cheek. Which term would the nurse utilize for documentation?

Vesicle

which priority assessment would the nurse include when providing care for a client who is experiencing depression

appetite activity status emotional status

which condition would the nurse suspect when an older adult has a thin white ring around the margin of her iris

arcus senilis

when conducting a health assessment for a school age child who is a new client to the pediatric practice, which question would the nurse ask the child and parents related to growth? Select all that apply

at which age did your child cut their first tooth what was your childs approximate length at 1 year of age what was your childs approximate weight at 6 months and 1,2,5 years of age

which condition would the nurse associate with a clients regular and slow respiratory rate?

bradypnea

which client is at a high risk for a rise in BP based on given data

client c

a client reports right ear hearing loss. when preforming a weber test with a tuning fork, the client hears the sound better with the right ear. which condition would the nurse suspect form these results?

conduction hearing loss

which condition would the nurse suspect when a client who underwent a physical exam two days ago reports itching

contact dermatitis

after conducting a falls risk assessment education session for the staff and observing falls risk assessments on the unit, which staff action needs review for corrective action

delegating fall assessments to assistive personnel

in which sequential order would the nurse assess the visual level of a client

direct client to stand 60cm away from eye level ask client to close his or her right eye gently close opposite eye to superimpose field of vision move finger equidistant between nurse and client ask client to report when they see finger

which type of interview would the nurse utilize when admitting a client to a clinic

directive

when the nurse completes a thorough assessment to identify the reason for a clients anxiety, which critical thinking attitude is involved in this situation

discipline

when would the nurse observe a client to assess their level of functioning?

during mealtime when preparing medications when administering insulin injections

For an older adult client, admitted to the health care facility following a stroke, which action would the nurse take when the clients cousin asks to see the clients health record?

explain medical health records are confidential

upon entering the exam room of a client and their spouse, which action would the nurse take when the client is withdrawn and appears fearful of the spouse

find a way to interview the client in private

which condition would the nurse suspect upon finding a bluish coloration of the skin during an assessment

heart disease

which condition is the nurse trying to prevent when teaching a client undergoing diuretic therapy to avoid working in the garden on hot summer days

heatstroke

a client reports difficulty breathing and the nurse auscultates bilateral wheezing in the anterior upper lobes. which potential rationale would explain this sound

high velocity airflow through an obstructed airway

which type of breathing pattern would a client experiencing hypercarbia exhibit

hpoventilation

the nurse is assigned to provide care for a new admit. the nurse performs a physical assessment reviews the admit form and examine the HCP RX. which taks would the nurse identify as the priorities in this clients plan of care

hygiene and comfort

which condition would the nurse suspect when an older adult is unable to see nearby objects

hyperopia presbyopia

A registered nurse teaches a new nurse about when a client with high blood pressure would follow up with the primary HCP. Which statement made by the new nurse indicates effective learning?

i will advise a client with a BP of 130/80 to follow up in a year

when measuring a clients blood pressure during a physical exam, which error will result in false high diastolic reading

inflating the cuff too slowly

which type of fever does a client have when experiencing fever spikes combined with a normal body temperature occurring at least once a day?

intermittent

an assessment of an 89 yo client yields a history of severe congenital spinal deformity. which condition would describe the nurses finding

kyphosis

which physical skin finding would the nurse associate with opioid abuse?

needle marks

while assessing a client the nurse identifies the ratio of the anteroposterior diameter and transverse diameter of the chest as 1:1. which finding supports this conclusion

older adult history of smoking chronic lung disease

when the triage nurse in the ED receives four clients simultaneously, which client would the nurse determine could be treated last

older adult male with laceration to finger

The nurse just arrived on the unit for his shift. Which action would the nurse take first to collect an initial set of data about the clients assigned to the nurses care?

participate in the bedside rounds

the nurse finds swelling in front of the left ear of a client reporting ear pain. The nurse would suspect involvement of which lymph node?

preauricular

a client who relocated to a new city for work is unable to cont the practice of walking for 30 min daily and exercising 5 days a week. which stage of trans theoretical model of health behavior change is the client experiencing

precontemplation

which client would experience impaired near vision

presbyopia hyperopia

which reliable site would the nurse utilize to assess a client for jaundice?

sclera

based on current research, when asked about spanking as a disciplinary technique, which response would the nurse utilize

spanking is strongly suggestive

which posture and location relative to the client would the nurse assume when performing a romberg test

standing to the sid of the client

which question would the nurse ask the client when obtaining their health history

tell me about your food habits do you use alcohol or tobacco have you ever experienced any allergic reactions

which diagnosis made by the nurse is helpful in providing the right nursing intervention for the client

the nurse identifies the client is not aware of perineal care and has impaired skin integrity

a client who does not understand english requires an interpreter. which action by the nurse may exacerbate health disparities?

the nurse talks only to the interpreter about the client

a client arrives at a health clinic reports, i am here to have my tuberculin skin test read. nurse notes a 7mm indurated area at injection site. which nurses statement describes this result

the result indicates you are infected with the TB organism

when providing care for a client with diarrhea, in which clinical indicator would the nurse anticipate a decrease?

tissue turgor

which related factor would the nurse attach to a nursing diagnosis

trauma of incision

client develops allergic reaction during physical assessment. which nurse statement indicates a lack of understanding

type IV immune reaction to latex occurs with first exposure

while assessing a clients skin, nurse notices clients skin is dry. which probable cause would nurse associate with this condition

use of hard soap frequent bathing

after presenting info about falls risk assessment to nursing staff, which participants statement needs review for corrective action

we will use admission fall assessment for the entire stay

while performing a physical assessment of a client, the nurse notices patchy areas with pigmentation loss on the skin, hands, and arms. with which probable cause would the nurse associate this finding

autoimmune disease

the RN reviews the various sites for assessing body temp with UAP. which UAP statement reflects effective learning

axilla is recommended to measure body temp in unconscious clients tympanic membrane is preferred temp artery is preferred site

a client with a history of cardiac dysrhythmias is admitted to the hospital due to fluid volume deficit caused by pulmonary infection. the RN assess the recorded vital signs, which vital sign requires reassessment

respiratory rate of 14 BP 120/80 O2 95

after a home assessment of an older adults fall risk, which intervention would the nurse suggest

secure rugs to prevent movement remove excessive pieces of furniture wear corrective lenses for distance perform exercises to strengthen lower

the nurse documents auscultation of coarse honcho in the anterior upper lung fields bilaterally that clears with coughing. which condition would the nurse associate with these sounds

turbulence due to muscular spasm and fluid or mucus in the larger airways

A recent immigrant from china is critically ill and dying. to meet this clients emotional needs, which question would the nurse ask when collecting info?

which family member do you prefer to receive information

which example would be a normal blood pressure for a 12 year old client?

110/65 mm Hg

a client weighed 210 pounds on admission to hospital. after 2 days of diuretic, the client weighs 205 pounds. which numerical value reflects the liters of fluid excreted by the client

2L

while assessing a clients pupils, a health care professional notices pupillary dilation. which drug would cause this condition

atropine

when gathering data for a clients health history, which intellectual factor would the nurse consider as a dimension

attention span

in the Ed, a nurse assessed a client who is unconscious experiencing severe bleeding due to a MVC and in hypovolemic shock. at which site would the nurse obtain the clients pulse rate

carotid femoral

when assessing an older client as they walk into the exam room, which finding would the nurse document as abnormal

client is wearing an excessive amount of cologne

when assessing a client who had a thyroidectomy yesterday, which cue would the nurse associate with an initial sign of hypocalcemia

paresthesias

for a client admitted with metabolic acidosis, which two body systems would the nurse assess for compensatory changes?

respiratory and urinary

for a client who had knee replacement surgery, which assessment finding gathered by the nurse is an example of subjective data?

the clients pain is a 7 on a scale of 1-10

The nurse providing care for a client whose forehead feels warm to the touch, uses a thermometer to obtain the clients temperature. Which action is the nurse taking?

validation

nurse admins an older adult clients meds via gastrostomy tube in the long term setting. which finding would necessitate holding the feedings and meds and notifying HCP immediately

ALL OF THEM

after assessing several clients the nurse would determine which client will require parenteral nutrition

a client with severe malabsorption disorder

While assessing a client who experienced an accident, the nurse found the client was unable to move her eyes laterally. Damage to which nerve led to this condition in the client?

abducens nerve

which info obtained during a clients health history would the nurse classify as biographical info

age insurance occupation

when assessing a patient for malnutrition the nurse would monitor for increase in liver enzymes and a decrease in which water soluble vitamin

all of the above

which factor would the nurse assess for a client reporting constipation

all of the above

which physical change would the nurse observe in a client with malnutrition? select all that apply

all of the above hypotension dry dull hair abdominal edema delayed wound healing depletion of muscle mass

which action would the nurse take when a client is receiving total parenteral nutrition

all of them

which scenario would contribute to health disparities

an english speaking nurse conducts an admission interview of puerto rican immigrant

when assessing risk factors, which question would the nurse ask a client who has developed pneumonia

are you diabetic

a client reports sleeping until non every day and taking frequent naps during the rest of the day. initially which action would the nurse take

arrange a referral for a thorough med eval

which step would the nurse take first when preparing a concept map for as assigned client?

arrange cues into clusters that form patterns

for a client who arrived at the health care facility for an appointment, which nurses action would be beneficial during the assessment interview?

ask about the clients current concerns

during a falls risk assessment, which action would the nurse take after learning the client experienced a recent fall

assess the circumstances of the fall including feelings and setting

while preparing to teach a client about self injection of insulin, which nurses action would increase the effectiveness of the teaching session

assess the clients barriers to learning self injection technique

an adolescent is taken to the ED after stepping on a nail. The nurse asks if the client has had a tetanus shot. they respond all immunizations are up to date. a few days later. the client is admitted with diagnosis of tetanus. which statement describes the nurses responsibility in this situation

assessment by the nurse was incomplete

which factor would elevate a clients oxygen sat

carbon monoxide

upon assessing an older adult client with a diagnosis of dehydration, which finding would the nurse identify as an early sign

change in mental status

while assessing clients hair, nurse notices client has headline. nurse teaches client about hair hygiene and lice control. which client statement indicates understanding of teaching

clean comb in ammonia water dilute vinger solution shampoo treatment

the nurse assess four different clients. for which client do the findings indicate the client is at risk for heart disease

client 2

when assessing LOC, which one of the four clients would the nurse identify as having the lowest neurological function

client 2

when assessing clients with GI problems, which client would the nurse suspect as having shigellosis

client 2

while providing care for four different clients, the nurse assess their breathing pattern. Which clients assessment findings indicate Cheyne-stokes respiration.

client 3

the nurse performed physical assessment for 4 female clients during general checkup. which client is most at risk of developing breast cancer

client B

the nurse assesses the body temp of four febrile clients over 4 days. which client is suffering from remittent fever

client C

nurse is assessing four clients. which client is at the highest medical risk of coronary heart disease and hypertension

client D

when a new nurse prepared pulse assessment plans for several clients, which clients assessment plan correctly yields effective results

client c

in which situation would the nurse consider family members as the primary source of information

client is an infant or child client is brought in as an emergency client is critically ill and disoriented

which client would have a health promotion nursing diagnosis

client who is willing to take a 30 min walk daily

which client would the nurse suspect as having an increased risk of hyperlipidemia

client with corneal arcus client with yellow lipid lesions on eyelids

which nurses action would help set the stage for a client centered interview? select all that apply

close the door after entering the room greet the client using his or her last name introduce oneself with a smile and explain the reason for the visit

in which sequential order would the nurse perform the assessment of a lesion

collect info about color size shape type grouping distribution observe for any exudate odor measure size of lesion in CM by using small clear ruler measure lesion for heigh width

for the client with a closed chest tube drainage system connected to suction, which assessment finding requires additional eval by the nurse

constant bubbling in the water seal chamber

after teaching a male client about measures to maintain sexual health and prevent transmission of STI which client statement indicates effective learning

consult primary HCP

of which cranial nerve does the nurse assess the function when asking the client to shrug their shoulders and to turn their head against passive resistance

cranial nerve XI

while assessing a pediatric client, an ophthalmologist notices child is unable to focus on object with both eyes simultaneously. which other finding would confirm diagnosis of strabismus select all

crossed appearance of eyes impaired extra ocular muscles

while assessing the nails of a client with diabetes, the nurse finds the skin on hands and feed are dry due to infection. which rationale would the nurse associate with this dryness

cutting nails after soaking them for 10 min

while assessing the eyes of a client, a HCP notices there is an obstruction to the outflow of aqueous humor. Which additional finding would support a diagnosis of glaucoma?

elevated intraocular pressure

which skin condition would the nurse associate with a client who's skin pathophysiology involves increased visibility of oxyhemoglobin caused by an increased blood flow due to capillary dilation?

erythema

when interviewing and assessing a 17 year old client, which finding alters the nurse to explore substance abuse with the adolescent

failing grades blood spots on clothing absenteeism from school long sleeved shirts in warm weather

when assessing a clients BP, obtained via the unsupported left arm, which reading error would the nurse expect

false high reading

During a survey, the community nurse meets a client who never visited a gynecologist after the birth of a second child. the client reports the clients mother or sister never had an annual gynecologic exam. which factor appears to be influencing the clients health practice

family practices

which client statement indicates a risk of breast cancer

first child at age 32 slight discharge from nipple consume 2-4 glasses of alcohol a day

nurse expects a client with an elevated temp to exhibit which indicator of pyrexia

flushed face increased pulse

which benefit would the nurse associate with using standard, formal, nursing diagnostic statements? select all that apply

fosters development of nursing knowledge provides precise definition of the clients problems distinguishes the nurses role from that of other care providers

which korotkoff sound represents the diastolic pressure for children?

fourth

when preparing to assess a client with CDIFF, which piece of PPE would the nurse put on before entering the clients room

full plastic gown

after assessing the muscle functionality of a client, the nurse assigns a grade of F on the lovett scale. which statement describes the muscle functionality of this client

full range of motion with gravity

when the defining characteristic of a clients assessment data apply to more than one diagnosis, which action would the nurse take

gather more info identify related factors review all defining characteristics

when preforming weight assessments for people within a community, which question would the nurse ask to determine a disease-related change in weight

have you noticed any unintentional weight loss in the last 6 months

while assessing a clients range of motion, the nurse explains adduction to the UAP. which UAP statement indicates effective learning

i will ask the client to move their arm toward their body

the nurse teaches a client about measures to promote health. which clients statement indicate effective learning. select all that apply

i will assess my own pulse rate after exercising i will follow my hypertension treatment plan consistently i will perform a self assessment of my heart rate using the carotid pulse

to ensure breast health, the nurse teaches a client about prevention and detection practices. which client statement indicates the need for further teaching

i will increase my daily meat consumption

after reviewing otoscope use for assessment of the ear with the nursing staff, which participants response reflects safe follow up care for when earwax goers the tympanic membrane

i will preform warm water irrigation

after the nurse teaches a client about various measures to protect against food-borne illness, which client statement reflects ineffective learning

ill wash my cooking utensils and cutting boards with tap water

arrange the sequence of events occurring during a fever in chronological order

immense sys response is triggered set point of hypothalamus is raised body temp increase pyrogens destroyed heat lost response

after an eye assessment, the nurse finds that the clients eyes are not focusing on an object simultaneously and appear crossed. which potential cause would the nurse associate with this condition?

impairment of the extra ocular muscles

When teaching a health awareness class, which situation would the nurse teach as being the highest risk factor for the development of a DVT

inactivity

for which clinical indicator would the nurse question a prescription for gastric lavage

increased serum bicarb level

the nurse is assessing four infants. currently, which infant has an abnormal weight

infant 2

The nurse, providing care for a client who underwent cardiac cath, found the clients skin was cool, tender to touch, with edema of 15.2 cm at the site of catheterization. Which condition would the nurse suspect?

infiltration

which term refers to the exaggerated posterior curvature of a clients thoracic spine

kyphosis

upon noticing a client with heart disease has digital cyanosis, which site would the nurse assess to confirm cyanosis

lips

after the nurse teaches a client who is obese measures to calculate the body mass index, which client statement indicates effective learning

lose at least half a pound each week make sure to eat food meeting daily nutrition should stay away form unhealthy foods

which clinical indicator is most commonly used to determine whether the client has a fluid deficit when reporting vomiting and diarrhea for three days

loss of body weight

when assessing a client with a history of marijuana use, which long term effect would the nurse associate with marijuana

lung cancer emphysema heart disease

when an african american client with renal failure reports the illness as a punishment for sins, which cultural health belief is the client communicating?

magicoreligious belief

a client with a family history of diabetes mellitus has been following a diet regimen recommended by the dietitian and walking for 45 minutes daily for the past 8 months. based on the trans theoretical model of health behavior change, which stage would the nurse document for this client?

maintenance

the nurse assesses a clients nails and finds a slight convex curve at the angle from the skin to nail base of about 160 degrees. which condition would the nurse suspect?

normal finding

which feature distinguishes nursing diagnoses from medical diagnoses

nursing diagnoses involve client nursing diagnoses involve sorting of health problems w/in nursing domain nursing diagnoses involve clinical judgment about clients response to health problems

which client would the nurse anticipate needing a referral to a support group for people with vision loss

obstruction of central vision

which nurses action is important for establishing good communication with the client who has impaired hearing?

obtaining the clients attention before speaking

for which age group would the nurse expect the occurrence of chronic illness to be the highest

older adults

which term refers to inflammation of the skin at the base of the nail

paronychia

a client asks the nurse about immunization against tetanus. before responding, which benefit would the nurse consider about the tetanus antitoxin

passive immunity is produced

the nurse providing care for a client who had a hysterectomy is concerned about the clients risk for postal thrombosis. nurse remembers that after pelvic surgery majority of pulmonary emboli begin as dvt in which area

pelvis and thighs

for which involuntary physiologic response would the nurse monitor development in a client experiencing pain

perspiring

upon entering an exam room for assessment of a confused client, which action would the nurse take

plan a focused physical assessment

the RN measures the clients BP as 130/80. when the UAP measured the same clients BP, the measurement was 120/90. which rationale would explain the measurement difference

poor fitting of the cuff deflating the cuff too quickly

while assessing an older adult during a regular health checkup, the nurse finds signs of elder abuse. which physical finding would confirm the nurses suspicion

presence of burns from cigarettes presence of bedsores presence of unexplained bruises on the wrist

when interpreting findings from a pain assessment, which factors would the nurse consider the most significant influences on a clients perception of pain

previous experience and cultural values

the nurse providing primary preventive care at a community health care center focuses on which type of activity?

promoting health in healthy individuals

which position would the nurse utilize to assess the musculoskeletal system, but contraindicated for clients experiencing chronic obstructive respiratory disease?

prone position

which assessment item needs to be documented on a client with restraints

pulse near restraint temp of restrained area skin integrity behavior leading up

while providing care for a client who is post, the nurse observed a pulse deficit during physical assessment. which pulses would the nurse use to assess the pulse deficit

radial and apical pulse

when assessing a client after abdominal surgery, which cue would the nurse use to form a data cluster

reports pain with movement has pain over surgical area client rates pain as 1 on scale of 0-10

upon assessing a client who is receiving chemotherapy, the nurse notes the client is using a scarf to cover her head. The nurse asks the client about coping with her altered body image. Which functional pattern would the assessment include?

self-perception- self tolerance pattern

which site would be safer and less expensive for temp measurement of a human

skin axilla

upon assessing a client who underwent abdominal surgery 10 days ago, the client reports abdominal pain. Which type of pain would the client experience?

visceral pain

a client admitted to the hospital with chest pain reports SOB, weakens, and vomiting, nurse suspects cardiac arrest. which site would the nurse check clients pulse rate

femoral

which part of the clients body would the nurse assess to confirm a diagnosis of frostbite

fingers ear lobes

while performing a neck assessment, the nurse finds the client has enlarged lymph nodes, history of IV drug use, and bisex activity. which possible diagnosis would the nurse suspect

HIV

based on provided data, which client would nurse suspect of having hypertension

client B

while providing post care for a client who had surgery to repair a deviated septum, the nurse would monitor for which complication associated with this type of surgery

expectoration of blood

when assessing a client with Hep A, which substance would the nurse be particularly careful to prevent transmission of the disease

fecal matter

when assessing an older adult male client, which clinical finding would the nurse expect as a response to the aging process

slowed near response forgetfulness about recent events reduced ability to maintain an erection

the nursing student plans to perform a pulse assessment. while preparing to assess the client, the RN asks the student to check the apical pulse after assessing the radial. which rationale supports the RNs request

the client may have a dysrhythmia

which factor would cause the nurse to identify an illness as chronic? select all that apply

the illness persists for longer than 6 months client may develop a life threatening relapse the illness affects the functioning of one or more systems